What Every Nurse Needs to Know About IUDs

• There are 2 main types of IUDs- copper and progesterone.
• The intrauterine device is the number one birth control worldwide is the number one long-acting reversible contraception (LARC) in the USA.
• Women of all ages can safely use this contraception.

Intrauterine devices (IUD)s are the most common method of birth control worldwide.  Oral contraceptive pills are a favorite in the United States, but the IUD is gaining some traction. 

 When women choose a long-acting reversible contraception (LARC), the IUD is a great choice.

They are: 

•  Highly effective 
• Reliable 
• Easy to use 
• Reversible 
• Relatively low cost 
• Effective as tubal ligation 

 The effectiveness of this contraceptive is 99% with perfect use.   It is so effective because there is a low chance of human error. Once it’s placed, women can forget about it for the most part.  

Types of IUDs Available

There are two types of intrauterine devices available, copper and the levonorgestrel (LNG).  There are 3 choices of LNG intrauterine devices in the USA. The most popular contains 52 mg, then 19.5 mg and 13.5 mg.  

The intrauterine device has had negative publicity in the 1970s.  Since then, an improvement in design has made it a great option. However  misinformation on risk of infection, ectopic pregnancies, and infertility, continue to cast doubt in the minds of women. 

IUD Misinformation

• The intrauterine device was thought to cause an increase in pelvic inflammatory disease (PID). However, through research we have found that the risk of PID with IUD users is the same or lower when compared to the risk of women who use oral contraceptives or the subdermal implant.   Additionally, the intrauterine device has NOT shown a greater risk of HPV, or progression of cervical cancer.   
• Another misconception with the IUD is that there is an increased risk of ectopic pregnancies. That is simply not true.  With that being said, If a woman gets pregnant whille using this type of contraceptive, there is a true risk of an ectopic pregnancy and requires immediate evaluation to determine the location of the pregnancy.
• The third common misconception is that the intrauterine device causes infertility.  There is no evidence that the IUD increases the risk of infertility.

Which Intrauterine Device Is Best for Me?

To best identify which intrauterine device to use, one must investigate a woman’s normal menstrual cycles and tolerance to unscheduled bleeding, menorrhagia and dysmenorrhea.   

 Copper Intrauterine Device

• The copper intrauterine device is a T-shaped device a little over an inch long. Copper threads coil around it and the copper ions are released in the uterus.   
• Copper is toxic to sperm and ovum.   
• It also creates a hostile environment in the uterus to prevent implantation if fertilization occurs.  
• It is attractive to women who want a method of birth control without hormones and one that is long acting.  For example, women with breast cancer should avoid hormones so this type of contraceptive might be the ideal birth control.   
• It will increase cramping and bleeding in most women.   
• Someone who already struggles with dysmenorrhea and/or menorrhagia might be better served using the LNG IUD since the cramping and bleeding is expected to worsen with the copper IUD.   

 Risks with the copper IUD: 

• Dysmenorrhea 
• Menorrhagia potentially leading to anemia. 
• Unknown allergy to copper and contraindicated in patients with Wilson’s Disease. 
• Discomfort during insertion.  (Pre-medicate with Naproxen to decrease pain with insertion.)  
• Slightly less effective than the LNG IUD. 
• Expulsion <5% or uterine perforation < 0.05 incidence 

 Benefits of the copper IUD 

• Non-hormonal 
• Ideal for women with progesterone side effects or who avoid hormones due to breast cancer. 
• Desire to maintain regular menstrual patterns 
• Decreased likelihood of unscheduled bleeding aka breakthrough bleeding (BTB) 
• Duration of use 12 years 
• Highly effective method 
• Emergency contraception 
• Not contraindicated in women with risks for cardiovascular disease or breast cancers.  
• Rapid return to fertility after removal. 
• Does not increase risk of PID 
• Discrete and usually not obvious to the partner

Progesterone (LNG) IUD 

• The LNG intrauterine device is slightly more effective than the copper intrauterine device. The LNG contains progesterone and makes the lining of the uterus thin and inhospitable for implantation.   
• The LNG is usually better tolerated than other progesterone containing birth control methods even including the OCPs.  Women can expect to feel about 10% of what they feel with the OCPs compared to the LNG intrauterine device.   
• Patients with a history of Wilson’s disease or a copper allergy should avoid the copper Iintrauterine device.  The LNG intraueterine device is a better option.  
• There is no estrogen in either intrauterine device, so women with a history of thromboembolic events can safely use the IUD. 

 Risks of the LNG IUD 

• Possible intolerance to the systemic progesterone effects in some women. 
• Unscheduled bleeding aka BTB. 
• Potential amenorrhea may be distressing.  
• Expulsion <5% or uterine perforation < 0.05 incidence 

 Benefits of the LNG IUD 

• The LNG intrauterine device is slightly more effective than the copper intrauterine device with failure rates for LNG IUDs of 0.07 vs 0.63 with the copper IUD.  
• Light menstrual flow. 
• Less dysmenorrhea 
• Rapid return to fertility once it is removed. 
• Does not increase risk of PID 
• Improves endometriosis symptoms. 
• Duration of use 3-8 years depending on the brand/dose. 
• Acceptable method of birth control for women who cannot take estrogen. 
• Off label use to treat menorrhagia. 
• Provides endometrial protection for women at risk for endometrial hyperplasia. 
• Not contraindicated in women with risks for cardiovascular disease or breast cancers.  
• Discrete and usually not obvious to the partner. 

 Acceptable use of the Intrauterine Device 

• A history of an ectopic pregnancy.  
• Nulliparous women 
• Women with a risk of or history thromboembolic events.  

  Contraindications of the IUD Not Previously Identified

• Active PID 
• Uterine abnormalities that distort the uterine cavity. 
• Pregnancy 
• Unexplained vaginal bleeding. 
• Breast cancer- avoid the progesterone intrauterine device. 
• Intolerance to unscheduled bleeding- avoid the LNG intrauterine device.

The Bottom Line

 The intrauterine device is an excellent choice for women of all ages.  It is generally easy to place, highly effective, cost effective and well tolerated. 

It gives women the opportunity to effective control their fertility at any stage of the childbearing years and improve their quality of life. 

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